United States blood pricing: A cross‐sectional analysis of charges and reimbursement at 200 <scp>US</scp> hospitals
Authors: Jeremy W. Jacobs, Marlon Diaz, Dory E. Arevalo Salazar, Albert Tang, Laura D. Stephens, Garrett S. Booth, Christoph U. Lehmann, Brian D. Adkins
Journal: American Journal of Hematology (2023)

A violin plot demonstrating listed chargemaster charges for RBC transfusion at 200 hospitals based on hospital ownership. A violin plot shows the volume of the samples at each point by width and lines correspond to the 25th percentile, median, and 75th percentile. Transfusion remains one of the most common procedures in healthcare; however, the exact acquisition cost and charges are unknown.1 While the average acquisition cost of a Red Blood Cell (RBC) unit is accepted to be approximately $200, the labor-based or associated costs of transfusion are more difficult to quantify.2 With recent United States (US) federal legislation, health systems are required to release chargemasters for all billable procedures and negotiated rates by the payor, resulting in large amounts of data available for healthcare providers and patients, including transfusion-related data.3 Blood acquisition is the largest expense for a hospital blood bank. Accurate characterization of charges and blood product costs is crucial in assessing practice and hospital budgeting. To determine the current costs of blood transfusion in the US, we performed a cross-sectional analysis of transfusion chargemaster, cash, and negotiated rate data at 200 US hospitals. This study was performed using publicly available online data; therefore, an institutional board review was not required. To determine charges, negotiated rates, and information availability, we assessed a purposive maximum variation sample of 200 hospitals. In December 2021, we queried the 100 most and 100 least cost-efficient hospitals according to Centers for Medicare and Medicaid Services (CMS) data.3 We assessed cost efficiency using the Medicare Spending Per Beneficiary (MSPB) score. According to CMS, the MSPB "evaluates hospitals' efficiency relative to the efficiency of the median national hospital. It assesses the cost of services performed by hospitals and other healthcare providers during the period immediately prior to, during, and following a beneficiary's hospital stay.3 The MSPB measures controls for variation in spending levels due to factors such as patient case mix index and geographic differences in Medicare payment levels. We obtained additional publicly available hospital data from the official CMS hospitals dataset and collected the US Department of Health & Human Services (HHS) region for each site. We also recorded hospital type and hospital ownership. Finally, if available, we collected the CMS Overall Hospital Quality Star Rating (OSR). The OSR, which ranges from a minimum of one star to a maximum of five stars, is determined based on the following objective and subjective measures: mortality, safety, readmission rate, patient experience, and timely and effective care. We analyzed 200 hospital websites for available chargemaster files to determine charges, payor rates, and information availability. We analyzed chargemaster files for data pertaining to list price, charge, or cash price for line items relating to transfusion. As CMS reimbursement rates were not widely available in the chargemaster files, we used the CMS final 2021 payment rate as published by the Association for the Advancement of Blood & Biotherapies for comparison.4 We determined negotiated rates from three of the largest US health insurance companies: UnitedHealth Group Inc. (Minnetonka, MN), Anthem Insurance Companies (now Elevance Health, Inc, Indianapolis, IN), and Aetna Inc. (Hartford, CT). As multiple rates were available, the highest reimbursement was selected for each insurer. We assessed the cost for the following current procedural terminology (CPT) and healthcare common procedure coding system (HCPCS) identifiers: Blood Typing (CPT 86905), RBC Antibody Screen (CPT 86850), Transfuse Blood/Comp (CPT 36430), RBC Leukocytes Reduced (HCPCS P9016), Platelet Pheresis Leukoreduced (HCPCS P9035), Plasma, Fresh Frozen (CPT 86927), Cryoprecipitate (HCPCS P9012), Granulocytes (HCPCS), P9050, Pheresis (HCPCS P9050), and Split Blood or Products (CPT 86985). We used the sum of the following CPT and HCPCS codes to determine the total charge of an RBC transfusion: CPT 86905, CPT 86850, CPT 36430, and HCPCS P9016. Data processing is described in Data S1. We performed statistical analysis using GraphPad PRISM 9.2.0 and assessed normality by Shapiro–Wilk test. Groups were compared using Mann–Whitney test. Variability was assessed by the coefficient of variation (CV). p-values <.05 were considered statistically significant. Hospital ownership and additional variables are summarized in Table S1. Access to chargemaster data varied in availability and quality. Most hospitals (84%, 168/200) had chargemasters available online. Negotiated rates were available for 49.5% (99/200) of institutions. Line-item rates were not consistently available, and each file did not include all payors. Among the 93 chargemasters with downloadable, machine-readable files, 71% (66/93) included negotiated rates, with cash rates being available for 93.9% (62/66), followed by United Health (54.5%, 36/66), Aetna (45.5%, 30/66), and Anthem (12.1%, 8/66). The median charge for an RBC transfusion procedure was $2388 (IQR $1798–$2492) with a CV of 104.5%. The median charge for an RBC unit was $634 (IQR $4452.60–$867.50). The charge for transfusion varied significantly depending on hospital ownership with proprietary hospitals having the highest median charge of $2884 (IQR = $2409–4932) and local government hospitals having the lowest median charge of $1901 (IQR = 1682–2406) (Supplemental Figure S1). The charge for transfusion was assessed against several other variables, but did not significantly associate with HHS region, type of hospital, or CMS quality score (p > .05). Lower OSR score hospitals (i.e., one star) had a median price of $2980 ($2793–$5733), whereas high-quality OSR score hospitals (i.e., five stars) had a median price of $2367 ($1396–$2873) (p = .43) (Figure S2). The median negotiated cash price for an RBC unit was $1388 ($1087–$1911) (n = 34). While full CPT availability to determine negotiated rates for health insurance companies was limited, the median rate for United Health was $1589 ($1198–$3093) (n = 19) (Table 1). Charge-to-reimbursement ratios (CR) were utilized to compare reimbursement rates by payors (Table 1, Table S2). They were significantly different (p = .02), with cash payors having the lowest rates and United Health having the highest (Table 1, Figure S3). Estimated CMS rates reimbursed are generally lower than either cash or private insurance payors (Table 1). Granulocytes, Pheresis had the highest charge of any blood product with a median price of $5787 ($2000–$7549) followed by Platelet Pheresis Leukoreduced, $1414 (755.90–2145) (Table 1). All blood products had high variability with CV ranging from 59.2% to 120.3%, with Cryoprecipitate having the greatest variability (Table S3). Related charges ranged with Transfuse Blood/Comp (36430) being the highest, $1282 (803.80–2281). CV was greatest for RBC Antibody Screen (86850), 225.9%, with an overall range of prices from $15.00 to 4725. Chargemaster availability was announced as a requirement for hospitals with final rule implementation on January 1, 2021.3 It has been shown that chargemasters historically were often not available, and when available, were difficult to use for the average health care consumer. The high rate of compliance with the chargemaster requirement in a contemporary cohort of hospitals is encouraging. However, we found a lag in quality as well as the availability of negotiated rates. As most of the data are incompletely shared by health systems, chargemasters do not yet provide reliable information for patients that permit cost transparency efforts. Our findings demonstrate significantly larger charges than the purchase prices for blood products with negotiated reimbursements much lower than charges. Charges were significantly higher in proprietary, or privately owned hospitals. While the RBC acquisition cost is ~$200 per unit for a hospital blood bank, the subsequent charge for the blood is ~$600 and the charge for the transfusion procedure is ~$2000. Of note, reimbursement by private insurers was the highest. The three private insurers had higher reimbursements compared to reported CMS-negotiated rates. Based on the 2019 National Blood Collection and Utilization Survey, which describes 10 852 000 annual RBC transfusions in the United States, the estimated total charges would equate to $25 914 576 000 for RBC transfusions alone.2 If all patients were covered by CMS, the total reimbursement would be $15 062 576 000. If all patients were insured, (using the United Health median rate) reimbursement would be $17 243 828 000. These estimates do not account for the divergent clinical scenarios that involve transfusions, and do not account for diagnosis-related groups (DRG) billing of inpatients but offer insight into the amount of money spent in the US on RBC transfusions. Each step of the transfusion process is expensive, and unfortunately, this is only a small fraction of the patient's complete care expenditures. Health expenditure (CHE) per capita was greatest in the US according to the most recent data from the WHO in 2020. CMS National Health Expenditure (NHE) data show healthcare expenditures in 2021 to approximate 4.3 trillion USD, or 18.3% of the gross domestic product (GDP).5, 6 Despite having the greatest healthcare expenditures, US life expectancy continues to decline relative to other developed nations. A major limitation of our study was the low compliance of many hospitals in providing pricing data. While this limited our ability to draw definitive conclusions, it highlights the lack of completeness and uniformity (in violation of US law), which likely will affect the patient's ability to interpret care costs.3 Most chargemaster files contained multiple negotiated rates for each payor, and when this was encountered, we used the highest rate, which may have added an element of inaccuracy. In a sample of 200 US hospitals, we found a significant paucity of chargemaster files. Several of the available chargemasters were in unusable formats despite US policy mandating available and machine-readable chargemaster files. Charges for blood products and transfusion varied widely among hospitals representing approximately $26 billion in charges for transfusions in the US. The authors are grateful to Dr. Abdullah Alswied for his assistance with data collection. No funding was received for this research. The authors declare no conflicts of interest related to this research. The data that support the findings of this study are available from the corresponding author upon reasonable request. Data S1. Supporting information. Figure S1. A violin plot demonstrating listed chargemaster charges for RBC transfusion at 200 hospitals based on hospital ownership. A violin plot shows the volume of the samples at each point by width and lines correspond to the 25th percentile, median, and 75th percentile. We used the sum of the following Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System codes to determine the total charge of an RBC transfusion: CPT 86905, CPT 86850, CPT 36430, and HCPCS P9016. Figure S2. A violin plot demonstrating listed chargemaster charges for RBC transfusion at 200 hospitals based on CMS Overall Hospital Quality Star Rating (OSR). A violin plot shows the volume of the samples at each point by width and lines correspond to the 25th percentile, median, and 75th percentile. The OSR is determined based on the following objective and subjective measures: mortality, safety, readmission rate, patient experience, and timely and effective care, with a higher score indicative of higher quality care.3 We used the sum of the following Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System codes to determine the total charge of an RBC transfusion: CPT 86905, CPT 86850, CPT 36430, and HCPCS P9016. Figure S3. A violin plot demonstrating charge to reimbursement ratios for transfusion-related charges for three of the largest US insurers at 200 hospitals. A violin plot shows the volume of the samples at each point by width and lines correspond to the 25th percentile, median, and 75th percentile. UnitedHealth Group Inc. (Minnetonka, MN), Anthem Insurance Companies (now Elevance Health, Inc, Indianapolis, IN), and Aetna Inc. (Hartford, CT) versus cash payors. 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